As the opioid crisis unfolds in San Francisco, one longstanding addiction treatment is becoming even more accessible than before.
Last month, the U.S. Health and Human Services Department announced an update to regulations for Opioid Treatment Programs, which are licensed to prescribe medications to patients with opioid-use disorders.
These medications — methadone and buprenorphine — have previously been available only for onsite consumption and prescribed during physical visits with physicians. But starting April 2, people will be able to take doses home with them and receive prescriptions via remote appointments.
The regulations around medications such as methadone haven’t changed much for the last 50 years, said Dr. Scott Steiger, a professor of medicine and psychiatry at UCSF and the deputy medical director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital and Trauma Center.
“Fifty years ago, when these were originally designed, the structure was focused on making sure that the methadone did not get into the hands of people who did not need it,” he said. “It was all about avoiding diversion and making sure that you don’t start somebody on methadone that’s not already dependent on an opioid.”
He said this was reasonable if safety was the main concern — but in reality, it kept the medications out of the hands of patients who needed them.
“People over the last five decades in the United States have learned that it’s really hard to be addicted to opioids, but it’s almost as hard to enter treatment,” he said.
The San Francisco Department of Public Health has eight licensed opioid-treatment programs, including the Opiate Treatment Outpatient Program at Zuckerberg. That program, which celebrated its 50th anniversary last year, currently treats more than 700 patients.
The City suffered its deadliest year for overdose deaths last year since 2020, reaching a total of 813 deaths. Steiger said methadone is one of the best methods to help keep people from overdosing.
“It’s probably more like a 90% reduction in overdose deaths,” he said, comparing the treatment to “not getting medication.” He noted that methadone also cuts all-cause mortality, or death from any reason, in half.
In the last two fiscal years, city health officials have treated more than 5,000 people with buprenorphine or methadone.
While both treatments can be effective for treating opioid-use disorder, methadone — a liquid concentrate often mixed in with water or juice — can more effectively retain patients. Buprenorphine, which often comes in a film or tablet, is not as potent and can hit a ceiling of effectiveness once a certain dosage is reached.
Buprenorphine could long be taken home, while methadone couldn’t, at least until the relaxation of restrictions during the COVID-19 pandemic. Steiger and his colleagues have had policies for patients “in remission” — or those who “haven’t gotten fully into abstinence mode” — allowing them to take home around two weeks’ worth of doses at a time and reducing their clinic visits to just twice a month.
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After a while, he said, he noticed that these patients were handling the take-home medication well, and after consulting with The City’s Street Medicine Team about what the maximum take-home dose would be appropriate for patients who were unhoused or living in shelters, settled on around two bottles at a time.
Now, the program has different levels of take-home medication based on what stage people are at in their recovery processes. Those who initially come in addicted to fentanyl but can safely hold onto medication, even if they’re not housed, can qualify for around four take-home doses a week.
“We split it up in a way that has people come in here Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday,” he said. “Then once they stabilize, we go to once a week.”
To ensure patients aren’t selling the medication or giving it to others who don’t need it, Steiger’s program requires patients to bring back their empty bottles.
According to DPH, before the pandemic relaxed regulations, only around 25% of patients qualified for take-home doses. After the rules were changed, 82% have received at least one take-home dose.
State officials’ permission to do this at the Opiate Treatment Outpatient Program at Zuckerberg is slated to expire in May, leaving take-home dosages up in the air.
“The ability to do these things is dependent upon the fact that we have applied to the state to have relief, or an exception, from California regulations, which are much more stringent than the federal regulation,” Steiger said.
It’s even more unclear how the new federal changes will affect the Zuckerberg Opiate Treatment Outpatient Program, as well as programs throughout the state.
“The new regulation changes coming from the federal government won’t help us unless the state allows us to have an exception to the state rules, or if the state changes their regulations,” he said.
Steiger theorized the situation could play out a few different ways: The state could allow an exception for all of San Francisco, or allow one on a clinic-by-clinic basis that would need to be reapplied for every year — or California could overhaul its regulations entirely.
The latter scenario could take a while, but Steiger said he’s hopeful it comes to fruition, especially because it would allow him to admit more patients who need treatment.
“There are many, many requirements that make it difficult for people to access treatments,” he said. “The new regulations from the federal government lower some of those barriers.”
